Differentiating Hip & Back

Problems

Dr Steve Longworth

MSK 2010

Rheumatology CPD Study Day

Kettering 23rd June 2010

The Hip & Back

• Where are they?

• History

• Examination

• Causes of Hip & Back Pain

• Red Flags

Where Are They?

Where’s The Hip?

• “SHOW ME where

you have your

pain”

• Rub

• Point

• Clutch

Where’s The Back?

� I asked 215 GPs

�When considering Mechanical Back Pain ‘the

back’ is the area on the dorsal surface of the

body

�From the occiput to the sacrum 44%

�Not specifically defined 42%

�The lumbar region bilaterally/centrally 16%

�From the 12th ribs to the gluteal folds 6%

The (Low) Back

• The (low) back is the

area on the dorsal

surface of the body

between the 12th ribs

and the gluteal folds

• “From the bottom of

the ribs to the bottom

of the bottom”

General Points To Remember (1)

• SYSTEMIC/SERIOUS PATHOLOGY

• Ask about other joints including upper limbs

• Are they systemically well?

• Fever WARMS

• Vital signs (Temperature/Pulse/Weight)

• Spinal referred/root pain may cause diffuse lower limb symptoms with no/minor back pain

• Patients are allowed more than one problem

General Points To Remember (2)

�Always watch the patient walk

�Can they weight bear?

� If you think it’s the back, screen the hip

� If you thinks it’s the hip, screen the back and

the knee

�Pain in the hip = examine the knee and vice

versa (L3)

�Proximal pain less well localised than distal

pain

History

• Age

• Occupation (“What do you actually do?”)

• Sports Hobbies Pastimes Activities

• PMH (Arthritis, Orthopaedic operations)

• Drugs (Current, Past, OTC, Complement)

• Treatment so far (Physio, Acupuncture etc.)

• FH

• SH Smoking (PVD) Alcohol (Neuropathy)

Onset

• Trauma

• Spontaneous –

Sudden or Insidious?

• Have they had it

before?

• Predisposing factors

– e.g. osteoporosis

The Hip

“Where’s the pain?”

• Where is the hip?

• Where is the leg?

• “Where’s the pain?”

Rub/Point/Clutch?

• Where did it start?

• Where has it been?

• Where is it now?

• The groin – a

minefield!

Examination of the Hip (1)

• STANDING

• Undressed

• Stick? Which hand?

• Posture + Wasting

• Alignment

• Gait

• Trendelenburg Test

• Lumbar spine

Examination of the Hip (2)

• SUPINE

• Limb length + SLR

• Flexion (Thomas’ Test)

• Rotations (pain, range, end feel)

• Trochanter tenderness

• PRONE

• Bilateral simultaneous medial rotation

• Palpate lumbar spine

Causes of Hip Pain in Children

• Under 1 – DDH

(CDH)

• 1-5 – Irritable hip

• 5-10 – Perthe’s

• 10-15 – Slipped upper

femoral epiphysis

• Any age – Sepsis

Causes of Hip Pain in Adults

• Osteoarthritis

• Other arthritides:

• Rheumatoid arthritis

• Psoriatic arthritis

• Ankylosing spondylitis

• Hip fracture

• Paget's disease

• Avascular necrosis

• Malignancy

• Infection

• Painful soft tissue conditions around the

hip:

• Trochanteric bursitis

• Snapping ilio-psoas tendon

• Torn acetabular labrum

OA Right Hip

Hip Fractures

Paget’s (acetabular protrusio)

Avascular Necrosis

• Most cases are idiopathic

• Associated conditions include:

• Excess alcohol

• Prolonged steroid therapy

• Pregnancy

• Hyperviscocity syndromes

• Working in pressurisedenvironments—for example, deep sea divers

Pelvic Mets from Ca Prostate

Classic Catches

• Paget’s, metastases,

myeloma

• Fractured pelvic

ramus

• Impacted sub-capital

fracture of femur

• Referred back

pain/spinal stenosis

• Stress fractures

The Back

Back Pain Diagnostic Triage

• Simple

• Sciatica

• Serious

Simple Mechanical Back Pain

• It isn’t simple!

• Or mechanical!

• >90% in Primary Care

• ‘Mechanical’Signature

• Exclude Sciatica and Serious

• ‘Good’ Prognosis

Sciatica

• >90% due to lumbar

disc herniation

• Spinal stenosis,

rarely tumours

• 90% of sciatica L4/5

and L5/S1 discs

• Limb pain dominant

Clinical Questions

• Sciatica is caused by compression of:

• The sciatic nerve 31%

• A lumbar nerve root 37%

• The spinal cord 0%

• Any of the above 31%

• None of the above 1.5%

Serious

• Age

• History of the pain

• PMH

• Systemically unwell

(Fever WARMS)

• Examination

“Wait a minute…maybe this isn’t

simple mechanical back pain!”

Examination - General

�Remember the therapeutic effect of examination!

�Systemically well? (weight/temp/pulse)

�Gait

� Indicate location of the pain

�Look for deformity & scars

Examination - Standing

• Spinal flexion

(modified Shrober’s)

• Heel/Toe walking

• Palpate for spasm

(tenderness

unhelpful)

• If no leg pain or Red

Flags – stop here!

• Pain behaviour?

Examination - Supine

• Lie down

• Rotate the hips

• SLRs

• Brief focused neurology

• Red flags - expand the

examination e.g. lungs,

breasts, abdomen, PR,

urine

Nerve Root Pain

• Unilateral leg pain greaterthan low back pain

• Pain radiating to foot or toes

• Numbness and paraesthesia in the same distribution

• Straight leg raising test induces more leg pain

• Localised neurology limited to one nerve root

Radiation of pain after injection of 0.1-0.3 ml 6% hypertronic saline into

sacrospinal muscle (yellow) and multifidus muscle (red). Note similarity to distribution of sciatic pain

Referred or Root Pain?

• Referred

• Back pain > Limb pain

• Poorly localised non-dermatomal ache above

the knee

• Root

• Limb Pain > Back Pain

• Dermatomal pain +/- sensory symptoms

below the knee

L3 Nerve Root Lesion

• Uncommon

• Anterior thigh pain

• Hip clear

• Weak knee extension

• Reduced/absent knee

reflex

• Femoral stretch

test

Spinal Stenosis

Any Questions?